Impact of Endoscopic Ultrasound Combined with Fine-Needle Aspiration Biopsy in the Management of Esophageal Cancer

Background and Study Aims: Endoscopic ultrasound (EUS) in combination with fine-needle aspiration biopsy (FNA) is a highly accurate method for the preoperative staging of esophageal cancer. Its impact on medical decision-making and the cost of care is unknown. This prospective case series was undertaken in order to determine the impact of EUS in combination with FNA on patients’ choice of therapy and on the cost of care.
Patients and Methods: Sixty consecutive patients with esophageal cancer, referred for preoperative EUS staging in a large tertiary-care academic medical center, were enrolled. The accuracy of EUS, the impact of EUS-based staging on the patients’ choice of therapy, and costs were studied.
Results: The accuracy rates for EUS combined with FNA in tumor and lymph-node staging were 83 % and 89 %, respectively. Twenty-five patients (42 %) had EUS stage I and II and were candidates for curative surgery. Twenty-eight patients (47 %) had stage III, and seven (12 %) had stage IV. All patients with stage I had surgery, while all patients with stage IV had medical therapy. The majority (62 %) of patients with stage II had surgery, while only a minority (25 %) of patients with stage III had surgery. Thirty-six patients (60 %) underwent medical therapy. Patients’ medical decisions in favor of surgical or medical therapy correlated strongly with the results of their EUS staging (P = 0.005), but not with age, sex, or referring physicians (surgeons vs. nonsurgeons). EUS-guided therapy potentially decreased the cost of care by $ 740 424 ($ 12 340/patient) by reducing the number of thoracotomies.
Conclusions: Patients’ decisions regarding therapy correlated with their overall tumor staging, suggesting that the information provided by EUS played a significant role in patients’ decision-making. The use of EUS in combination with FNA reduces the cost of managing patients with esophageal cancer.

References

• 1 Rösch T, Classen M. Gastroenterologic endosonography. Stuttgart; Thieme 1992 45
• 2 Chang K J, Katz K D, Durbin T E. et al . Endoscopic ultrasound-guided fine-needle aspiration.  Gastrointest Endosc. 1994;  40 694-699
• 3 Wegener M, Adamek R J, Wedmann B, Pfaffenbach B. Endosonographically guided fine-needle aspiration puncture of paraesophagogastric mass lesions: preliminary results.  Endoscopy. 1994;  26 586-591
• 4 Wiersema M J, Kochman M L, Cramer H M. et al . Endosonography-guided real-time fine-needle aspiration biopsy.  Gastrointest Endosc. 1994;  40 700-707
• 5 Giovannini M, Seitz J F, Monges G. et al . Fine-needle aspiration cytology guided by endoscopic ultrasonography: results in 141 patients.  Endoscopy. 1995;  27 171-177
• 6 Vilmann P, Hancke S, Henriksen F W, Jacobsen G K. Endoscopic ultrasonography-guided fine-needle aspiration biopsy of lesions in the upper gastrointestinal tract.  Gastrointest Endosc. 1995;  41 230-235
• 7 Erickson R A, Sayage-Rabie L, Avots-Avotins A. Clinical utility of endoscopic ultrasound-guided fine needle aspiration.  Acta Cytol. 1997;  41 1647-1653
• 8 Gress F G, Savides T J, Sandler A. et al . Endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography in the preoperative staging of non-small-cell lung cancer: a comparison study.  Ann Intern Med. 1997;  127 604-612
• 9 Nguyen P, Rezvani F, Chang K J. Endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (FNA) thoracentesis of pleural fluid [abstract].  Gastrointest Endosc. 1997;  45 A176
• 10 Nguyen P, Sze G, Rezvani F, Chang K J. Endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (FNA) of abdominal fluid [abstract].  Gastrointest Endosc. 1997;  45 A176
• 11 Nguyen P, Chang K J. Endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (FNA) of liver lesions in patients with gastrointestinal malignancies.  Gastrointest Endosc. 1999;  50 357-361
• 12 Jafri I, Saltzman J R, Colby J, Krims P. Evaluation of the clinical impact of endoscopic ultrasonography in gastrointestinal disease.  Gastrointest Endosc. 1996;  44 367-370
• 13 Nickl N J, Bhutani M S, Catalano M. et al . Clinical implications of endoscopic ultrasound: the American Endosonography Club Study.  Gastrointest Endosc. 1996;  44 371-377
• 14 Beahrs O H, Henson D E, Hutter R V, Kennedy B J. Manual for staging cancer. 4th ed. Philadelphia; Lippincott 1992